Should ED Administrators Start Reducing CT Usage?

Dear Director,
I heard some colleagues in another institution talking about the pressure they’re under to reduce CT utilization. Should I start looking into this now, before I get the pressure, or can I afford to keep things business as usual?

I first got pressure from a hospital CEO to reduce CT utilization after our ED underwent tremendous volume growth and a proportional increase in CT use. This led to costly maintenance to the scanner. I survived the CEOs rantings by showing that our utilization rate (CTs per 100 patients) was in line with accepted standards.

Reducing CT utilization became an administrative priority around 2010 with the passage of The Patient Protection and Affordable Care Act (PPACA). The Act incentivizes value-oriented and cost-conscious care by altering the financial incentives that drive utilization. The PPACA attempts to slow the growth and cost of medical imaging by varying payment according to physicians’ adherenence to known criteria. CMS then developed quality measures that are impacted by ED utilization. Some measures, like eliminating a sinus CT when doing a brain CT, seem like no-brainers and should be easy for us to do. Other measures are more difficult. OP-15 looked at Medicare patients who received a brain CT in the ED for atraumatic headache. This publicly reported measure was the big worry for both EPs and hospital administrators and it really increased the momentum of reducing CT utilization. Not surprisingly, OP-15 was opposed by ACEP and ultimately suspended by CMS.

While this bought EM a little time to figure out CT utilization, some measures are still posted publicly and by fiscal year 2015, 20% of a hospital’s “total performance score,” will be determined by its performance on the Medicare Spending per Beneficiary measure. Therefore, since utilization is still on the hospital administrator’s radar, it still needs to be on ours.

Benefits of Reducing Utilization
Plenty of literature clearly shows the increase in CT utilization over the last several decades. But even in the period of omnipresent CTs, utilization between 1996-2007 increased 330%. I am not advocating cutting tests that are appropriate and indicated, but there are a variety of benefits that will be derived by decreasing utilization of high cost imaging. From a societal perspective, physicians should be conscious of the cost of the tests that we are ordering and consider the impact they place on total healthcare expenditures. We also have a responsibility to our patients, particularly pediatric patients, to consider the radiation exposure that patients receive or the risk of a patient developing a contrast nephropathy. Although the radiology community is working to decrease radiation exposure in certain tests through enhanced technology and programs exist for a hospital to tally a patient’s lifetime radiation exposure, it is ultimately our responsibility to decide if we need the test or not. Finally is the impact CTs have on our length of stay (LOS). For EDs bursting at the seams, reducing LOS seems to be the secret sauce for improving all metrics, from door-to-doc to patient satisfaction, and these ultimately translate into a happier environment. As we all try to become more efficient, and don’t forget that LOS is now a publicly reported measure, eliminating unnecessary tests seem to be one solution.

What’s in the future
The PPACA legislated two types of global payment models that may transition away from healthcare’s current fee-for-service model. First are accountable care organizations (ACOs), which are networks of providers and facilities that are financially accountable for all health care costs incurred by their population over time. If costs are reduced and patients have good outcomes, the ACO may share in these savings. A bundled care payment refers to the single payment for all of the care and providers that are involved in a patient’s episode of care. Imagine the patient comes to the ED, undergoes a variety of tests (lab and radiology), but the payment is given to the hospital to then divide up between the hospital facility fee, the EP, the radiologist, the lab, etc…rather than paying each fee independently. It’s unclear how EDs and emergency physicians will be impacted by these payment structures.

Where do we go from here
As emergency physicians, utilization needs to remain on our radar. ED medical directors need to work with their IT partners to get accurate utilization metrics, both for the department and individual providers. There is often a tremendous amount of provider variability that is not accounted for by differences in patient acuity. There are already attempts at benchmarking ED utilization and at some point we may see hospital administrators asking for the removal of a high utilizer. The good news is that there are certain strategies that we can implement to eliminate some testing while maintaining a high level of quality and patient safety.

Some that we have implemented in our ED are the use of high sensitivity d-dimer measurements as the initial diagnostic test in patients with low pre-test probability of venous thromboembolism and algorithm use to reduce head CTs on patients with mild closed head injuries or with uncomplicated headache without high risk features.

There are obvious pitfalls to over-emphasizing a reduction in CTs. Namely that a provider might neglect to order an appropriate test for the sake of the benchmarks. As medical directors dive into the utilization data, we need to balance appropriateness of test ordering and utilization rates within the different patient populations and acuities of patients that may exist between providers within our own department and across departments.

There is likely no benefit to decreasing ED CT utilization if the end result is higher healthcare costs, such as admitting a patient for observation rather than doing a CT which if negative would result in the patient’s discharge.

While it’s unclear how reimbursement will occur, it’s likely that the future will bring a change in the payment structure. As physicians, we have a responsibility to provide high quality, evidence based care while balancing cost, radiation exposure, and patient risk. Making knee jerk reactions to minimize CTs will not be in anyone’s best interest but combining carefully thought out evidence based guidelines with good data that allows us to include guidelines and medical decision making should make the transition to the new payment and utilization world smoother.

Michael Silverman, MD, is a partner at Emergency Medicine Associates and is chairman of emergency medicine at the Virginia Hospital Center.

Dr. Sverha is director of clinical operations in the ED at the Virginia Hospital Center.